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Journal: The international journal of lower extremity wounds


Osteomyelitis frequently complicates infections in the feet of patients with diabetes. Gram-positive cocci, especially Staphylococcus aureus, are the most commonly isolated pathogens, but gram-negative bacteria also cause some cases of diabetic foot osteomyelitis (DFO). These gram-negatives require different antibiotic regimens than those commonly directed at gram-positives. There are, however, few data on factors related to their presence and how they influence the clinical picture. We conducted a retrospective study to determine the variables associated with the isolation of gram-negative bacteria from bone samples in cases of DFO and the clinical presentation of these infections. Among 341 cases of DFO, 150 had a gram-negative isolate (alone or combined with a gram-positive isolate) comprising 44.0% of all patients and 50.8% of those with a positive bone culture. Compared with gram-positive infections, wounds with gram-negative organisms more often had a fetid odor, necrotic tissue, signs of soft tissue infection accompanying osteomyelitis, and clinically severe infection. By multivariate analysis, the predictive variables related to an increased likelihood of isolating gram-negatives from bone samples were glycated hemoglobin <7% (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.5) and a wound caused by traumatic injury (OR = 2.0, 95% CI = 1.0-3.9). Overall, patients whose bone samples contained gram-negatives had a statistically significantly higher prevalence of leukocytosis and higher white blood cell counts than those without gram-negatives. In conclusion, gram-negative organisms were isolated in nearly half of our cases of DFO and were associated with more severe infections, higher white blood cell counts, lower glycated hemoglobin levels, and wounds of traumatic etiology.

Concepts: Immune system, Bacteria, Microbiology, Staphylococcus aureus, Infection, Wound, Osteomyelitis, Gram-positive bacteria


Chronic skin ulcers require extensive, systemic differential diagnosis; thus, they are difficult to diagnose and treat. Transient or persistent hypercoagulable states are among the rare causes of skin ulcers. Here, we present the case of a 27-year-old woman patient with recurrent, nonhealing skin ulcers of 8 years' duration, who had been treated unsuccessfully with various medications under different diagnoses at different clinics. On admission, a skin biopsy demonstrated occlusive vasculopathy, and the search for an inherited hypercoagulable state revealed a heterozygous factor V Leiden mutation. The patient was treated with anticoagulants and hyperbaric oxygen. On treatment, the skin lesions healed and did not recur.

Concepts: Oxygen, Medical terms, Diagnosis, Medical diagnosis, Differential diagnosis, Hyperbaric medicine, Factor V Leiden, Oxygen toxicity


The diabetic foot (DF) is a complex pathology involving the lower limb of 8 to 10 million people around the world, and its prevalence is rising, creating a dramatic need for effective therapeutic answers. The multidisciplinary DF clinic has been proposed as a model to fight this complication from the International Working Group on Diabetic Foot (IWGDF) inside a more articulated 3-level organization strategy. The organization and technical aspects of this strategy, together with the characteristics of each of the 3 levels have been analyzed and described in the article, together with the aims and limitations of each of the levels to cope with a 3-dimensional pathology involving systemic, local, and logistic aspects. The implementation of this model in Europe produced positive results measured so far in at least 2 nationwide experiences, in Germany and in Italy, and it should be taken in account whenever health policies apply to the DF issue.

Concepts: Million, Management, Policy, Need, Limb, Want, Economics terminology


Hydrofluoric acid, a highly dangerous substance, can cause tissue damage and systemic toxicity by its unique mechanisms. Many cases of severe faciocervical burns due to hydrofluoric acid exposure are lethal. Herein, we present a case of 37-year-old man who suffered from hydrofluoric acid burns to his face, anterior neck, lips, and nasal cavity. On admission, this patient coughed with much sputum, and the chest auscultation detected rough breath sounds, wheezes, and very weak heart sounds, indicating possible inhalation injury. This case highlights the extreme complexity of managing this kind of injury. Timely and accurate wound treatment and respiratory tract care, as well as active systematic support treatment, played vital roles in the management of this patient.

Concepts: Heart, Respiratory physiology, Respiratory system, Inhalation, Mucus, Auscultation, Nasal cavity, Hydrofluoric acid


Patients infected with human immunodeficiency virus (HIV) can present with 4 pathology types: drug-induced vasospasm (ergotism), arterial limb ischemia, critical limb ischemia, and aneurysm. Although these problems are common vascular problems, they result in increased morbidity and mortality in HIV-infected patients, especially aneurysm. Patients with these problems tend to be diagnosed with difficulty because of atypical symptoms and signs. Because of lack of data in treatment outcome literature, our report explores and provides information on HIV infection-related arteriopathy. There were 17 patients in our 5-year review. There was no death in patients except the aneurysm type. The survival of aneurysm patients was significantly lower than from other pathologies (P = .003). Our case series showed good short-term outcome, and patients were not at risk for less beneficial surgical procedures.

Concepts: HIV, AIDS, Immune system, Pathology, Hospital, Medical diagnosis, Immunodeficiency, Chiang Mai


Erysipelas are common soft tissue infections responding to first-line antibiosis. Because of factors of related to responsible bacteria and host, complications can occur that need extensive surgery in addition to intensified drug therapy. We report on a 65-year-old woman with leg ulcer who developed an absceding and necrotizing panniculitis of the affected leg complicating erysipelas. Escherichia coli and Pseudomonas aeruginosa were identified. Debridement and surgical removal of inflamed subcutaneous adipose tissue was decisive to interrupt the process. Wound bed preparation was realized by vacuum-assisted closure. Final wound closure was done by split-skin mesh graft. Complicated skin and skin structure infections need a combined approach of intensified antibiosis and surgery to save life.

Concepts: Immune system, Inflammation, Bacteria, Infection, Escherichia coli, Pseudomonas aeruginosa, Tissues, Chronic wound


The aims of this study were to evaluate factors influencing the distribution of ciprofloxacin in tissue of patients suffering from varying degrees of peripheral arterial disease (PAD). Blood and tissue samples were collected from patients undergoing debridement or amputation procedures and the amount of ciprofloxacin in them was determined using high-performance liquid chromatography. All patients were administered a 200-mg dose of intravenous ciprofloxacin prior to the debridement or amputation procedure. Data, including patient gender, age, type of diabetes, presence of neuropathy, medications taken, and severity of PAD were collected. These data were then analyzed to determine factors influencing the concentrations of ciprofloxacin in tissue of the lower limbs. The Kruskal-Wallis test, Spearman correlation, and chi-square test were used to relate covariates and fixed factors with the concentration of ciprofloxacin in tissue. Following bivariate analysis, a 3-predictor regression model was fitted to predict tissue concentrations of ciprofloxacin given information about these predictors. Blood and tissue samples were collected from 50 patients having an average age of 68 years. Thirty-three patients were males and 35 patients suffered from type 2 diabetes. The average number of medications that these patients were taking was 10. The majority of patients (n = 35) were suffering from severe PAD. Tissue concentrations of ciprofloxacin were mainly related to plasma concentrations of ciprofloxacin, number of medications that the patients were taking and severity of PAD.

Concepts: Statistical tests, Statistics, Blood, Spearman's rank correlation coefficient, Prediction, Non-parametric statistics, Chromatography, High performance liquid chromatography


Despite ongoing smoking cessation efforts and optimized perfusion, failed wound closure in the presence of peripheral arterial disease (PAD) and diabetes are common. A clinical effectiveness review was conducted in actively smoking diabetic patients diagnosed with PAD, treated with serial applications of a viable intact cryopreserved human placental membrane (vCPM) (Grafix, Osiris Therapeutics Inc, Columbia, MD) for recalcitrant lower extremity ulcerations (n = 6). More than half of the patients were not candidates for revascularization. Baseline vascular status in 5 of 6 lower-extremity wounds remained unchanged throughout the entire course of vCPM treatment. Daily cigarette consumption averaged 18 cigarettes per patient. Mean wound duration and mean surface area was 53 weeks and 4.6 cm(2), respectively. Mean number of vCPM applications and time to closure was 7.0 grafts in 7.8 weeks. There were no wound-related infections or amputations and no vCPM-related adverse events. All 6 wounds remained closed at the 12-month follow-up visit. In conclusion, vCPM demonstrated clinically effective outcomes in 6 previously nonhealing ulcerations despite ongoing smoking habits in the presence of PAD and diabetes.

Concepts: Clinical trial, Infection, Smoking, Cigarette, Nicotine, Smoking cessation, Wound, Gangrene


Several wound classification systems are used to assess diabetic foot wounds. The recommendations for their use depend on the authors and foot associations. In this study, we compared Saint Elian score system, WIfI classification and Texas in 101 patients with foot wounds, and we followed them for a median of 149 days, finding differences both in the assigned risk and in the association with major amputation and wound healing. Saint Elian and WIfI scores match when Saint Elian is low or high risk but not when it is moderate. WIfI stages correlate with major amputation and wound healing. Saint Elian III correlates with major amputation. Prevalence of major amputations was 41% for WIfI 4 and 83% for Saint Elian III. WIfI 1 and 2 and Saint Elian I had a rate of wound healing of 80% to 85%. Stages 1 and 2 of WIfI score behave similar with regard to wound healing, 82% and 80% (P = .71), and major amputation, 0% and 10% (P = .68). Stages I and II of Saint Elian have the same rates of major amputation, 0% and 8% (P = .66), but not of wound healing, 85% and 51% (P < .05). The optimal cut point for detecting major amputation in Saint Elian is 18, with a sensitivity of 90.9 and specificity of 84.9, but there is no recommended cut point for wound healing. These classifications are validated for their use in diabetic foot wounds and to assess amputation risk, helping physicians make decisions and talk to the patients about prognosis.


The “diabetic foot attack” is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of “time is tissue” and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.

Concepts: Inflammation, Myocardial infarction, Atherosclerosis, Infection, Stroke, Surgery, Infarction, Necrosis